Toe walking in Children

Toe walking, or equinus gait, may occur in otherwise normal children or in children with underlying disorders.

Secondary Toe Walking

Equinus is common in children with a variety of other primary problems. Toe walking is often in children with autism or those with developmental delay.

Accessory soleus is a rare congenital deformity in which the body of the soleus muscle extends to the ankle. This produces equinus and a fullness on the medial side of the ankle. Operative lengthening may be necessary.

Idiopathic Toe Walking

ITW in infants and young children is uncommon and usually due to shortening of the triceps muscle.

Etiology The cause is unknown but the problem appears to be familial. Examination of the parents often demonstrates some asymptomatic tightness of the heel-cord.

Natural history The condition is always bilateral and present when the toddler begins to walk. The contracture develops over the first few years, limiting ankle dorsiflexion. Later in childhood, the condition appears to improve spontaneously. Heel-cord contracture may increase the risk of overuse syndromes and the development of a symptomatic flatfoot with heel valgus, and lateral column shortening may occur during the second decade.

Clinical features include an onset with the initiating of walking, variable toe walking, altered shoe wear, reduction in ankle dorsiflexion, and a normal neurological examination. The diagnosis is made by the history and examination. Laboratory studies are seldom necessary. The diagnosis is made by exclusion.

Management is controversial.

Nonoperative Traditionally, physical therapy, casting, bracing, and botox injections have been recommended. Temporary improvement is often followed by recurrent equinus. These treatments are unlikely to affect the long-term outcome. If nonoperative treatment is undertaken, the least disruptive option is the articulated AFO with plantarflexion block.

Heel-cord lengthening Correct persisting deformity by lengthening of the heel-cord after the age of 4. Percutaneous or open procedures are effective. Immobilize in a short-leg walking cast for 4 weeks following the procedure. Recurrence is rare.